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Department of Veterans AffairsOffice of Inspector General

Office of Healthcare Inspections

Report No. 14-04218-92

Combined Assessment Program Review of the

St. Cloud VA Health Care System St. Cloud, Minnesota

January 26, 2015

Washington, DC 20420

To Report Suspected Wrongdoing in VA Programs and Operations Telephone: 1-800-488-8244

E-Mail: [email protected] (Hotline Information: www.va.gov/oig/hotline)

mailto:[email protected]

http://www.va.gov/oig/hotline

CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN

Glossary

CAP Combined Assessment Program

CLC community living center

EAM emergency airway management

EHR electronic health record

EOC environment of care

facility St. Cloud VA Health Care System

FY fiscal year

MH mental health

MRI magnetic resonance imaging

NA not applicable

NM not met

OIG Office of Inspector General

QM quality management

RRTP residential rehabilitation treatment program

VHA Veterans Health Administration

VA OIG Office of Healthcare Inspections


Table of Contents Page

Executive Summary ................................................................................................... i

Objectives and Scope ................................................................................................ 1 Objectives ............................................................................................................... 1 Scope...................................................................................................................... 1

Reported Accomplishment........................................................................................ 2

Results and Recommendations ................................................................................ 3 QM .......................................................................................................................... 3 EOC ........................................................................................................................ 7 Medication Management......................................................................................... 10 Coordination of Care ............................................................................................... 12 Continuity of Care ................................................................................................... 13 MRI Safety .............................................................................................................. 14 EAM ........................................................................................................................ 16 MH RRTP ............................................................................................................... 18

Appendixes A. Facility Profile .................................................................................................... 20 B. Strategic Analytics for Improvement and Learning ............................................ 21 C. Veterans Integrated Service Network Director Comments ................................ 24 D. Facility Director Comments ............................................................................... 25 E. Office of Inspector General Contact and Staff Acknowledgments ..................... 27 F. Report Distribution ............................................................................................. 28 G. Endnotes ........................................................................................................... 29

VA OIG Office of Healthcare Inspections


Executive Summary

Review Purpose: The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care, and to provide crime awareness briefings. We conducted the review the week of November 3, 2014.

Review Results: The review covered eight activities. We made no recommendations in the following seven activities:

Quality Management

Environment of Care

Medication Management

Coordination of Care

Continuity of Care

Emergency Airway Management

Mental Health Residential Rehabilitation Treatment Program

The facility’s reported accomplishment was increasing access to primary and specialty medicine services.

Recommendation: We made a recommendation in the following activity:

Magnetic Resonance Imaging Safety: Ensure radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan.

Comments

The Veterans Integrated Service Network and Facility Directors agreed with the Combined Assessment Program review finding and recommendation and provided an acceptable improvement plan. (See Appendixes C and D, pages 24–26, for the full text of the Directors’ comments.) We will follow up on the planned actions until they are completed.

JOHN D. DAIGH, JR., M.D. Assistant Inspector General for

Healthcare Inspections

VA OIG Office of Healthcare Inspections i


Objectives and Scope

Objectives

CAP reviews are one element of the OIG’s efforts to ensure that our Nation’s veterans receive high quality VA health care services. The objectives of the CAP review are to:

Conduct recurring evaluations of selected health care facility operations, focusing on patient care quality and the EOC.

Provide crime awareness briefings to increase employee understanding of the potential for program fraud and the requirement to refer suspected criminal activity to the OIG.

Scope

The scope of the CAP review is limited. Serious issues that come to our attention that are outside the scope will be considered for further review separate from the CAP process and may be referred accordingly.

For this review, we examined selected clinical and administrative activities to determine whether facility performance met requirements related to patient care quality and the EOC. In performing the review, we inspected selected areas, conversed with managers and employees, and reviewed clinical and administrative records. The review covered the following eight activities:

QM

EOC



Continuity of Care

MRI Safety

EAM

MH RRTP

We have listed the general information reviewed for each of these activities. Some of the items listed may not have been applicable to this facility because of a difference in size, function, or frequency of occurrence.

VA OIG Office of Healthcare Inspections 1


The review covered facility operations for FY 2013, FY 2014, and FY 2015 through October 31, 2014, and was done in accordance with OIG standard operating procedures for CAP reviews. We also asked the facility to provide the status on the recommendations we made in our previous CAP report (Combined Assessment Program Review of the St. Cloud VA Health Care System, St. Cloud, Minnesota, Report No.12-01876-239, August 6, 2012).

During this review, we presented crime awareness briefings for 167 employees. These briefings covered procedures for reporting suspected criminal activity to the OIG and included case-specific examples illustrating procurement fraud, conflicts of interest, and bribery.

Additionally, we surveyed employees regarding patient safety and quality of care at the facility. An electronic survey was made available to all facility employees, and 456 responded. We shared summarized results with facility managers.

In this report, we make recommendations for improvement. Recommendations pertain to issues that are significant enough to be monitored by the OIG until corrective actions are implemented.

Reported Accomplishment

Primary and Specialty Medicine Access

The facility has improved patient access to care in primary and specialty clinics. In FY 2014, primary care new patient wait times improved by 35 percent from quarter 1 to quarter 4 and exceeded the national target. To meet access demands, the Patient Aligned Care Teams have closely monitored schedules, identified areas of low utilization, and reformatted schedules to increase efficiency of clinic access. The facility hired additional primary care providers to assist in providing timely access to primary care services. The Patient Aligned Care Teams also used the chronic disease management model and alternative methods for patient care such as secure messaging, telephone calls, and telehealth services.

The Primary and Specialty Medicine Service Line has significantly increased enrollment in the Home Telehealth Program and exceeded the Veterans Integrated Service Network 23 goal of 70 percent of Patient Aligned Care Teams enrolled in Home Telehealth Program services with quarter 3, FY 2014 data at 87.9 percent. The Primary and Specialty Medicine Service Line has also exceeded national goals for secure messaging and has increased specialty services to include nephrology, neurology, pain clinic, and a call center at the Brainerd Community Based Outpatient Clinic. Additionally, applying InterQual® Criteria1 to all rheumatology consults prior to scheduling has positively affected new patient wait times for the rheumatology clinic, which are now at 9 days, significantly improving from the former wait time of 90 days.

1 InterQual®Criteria is a tool help health care organizations assess the clinical appropriateness of patient services.



Results and Recommendations

QM

The purpose of this review was to determine whether facility senior managers actively supported and appropriately responded to QM efforts and whether the facility met selected requirements within its QM program.a

We conversed with senior managers and key QM employees, and we evaluated meeting minutes, eight credentialing and privileging folders, and other relevant documents. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed Findings Recommendations There was a senior-level committee responsible for key quality, safety, and value functions that met at least quarterly and was chaired or co-chaired by the Facility Director. The committee routinely reviewed

aggregated data. QM, patient safety, and systems redesign

appeared to be integrated. Peer reviewed deaths met selected requirements: Peers completed reviews within specified

timeframes. The Peer Review Committee reviewed

cases receiving initial Level 2 or 3 ratings. Involved providers were invited to provide

input prior to the final Peer Review Committee determination.

Credentialing and privileging processes met selected requirements: Facility managers reviewed privilege forms

annually and ensured proper approval of revised forms.



NM Areas Reviewed (continued) Findings Recommendations Facility managers ensured appropriate

privileges for licensed independent practitioners. Facility managers removed licensed

independent practitioners’ access to patients’ EHRs upon separation. Facility managers properly maintained

licensed independent practitioners’ folders. NA Observation bed use met selected

requirements: The facility gathered data regarding

appropriateness of observation bed usage.

The facility reassessed observation criteria and/or utilization if conversions to acute admissions were consistently 25–30 percent or more.

The process to review resuscitation events met selected requirements: An interdisciplinary committee reviewed

episodes of care where resuscitation was attempted.

Resuscitation event reviews included screening for clinical issues prior to events that may have contributed to the occurrence of the code.

The facility collected data that measured performance in responding to events.

NA The surgical review process met selected requirements: An interdisciplinary committee with

appropriate leadership and clinical membership met monthly to review surgical processes and outcomes.



NM Areas Reviewed (continued) Findings Recommendations The Surgical Work Group reviewed

surgical deaths with identified problems or opportunities for improvement.

The Surgical Work Group reviewed additional data elements.

Clinicians appropriately reported critical incidents. The safe patient handling program met selected requirements: A committee provided program oversight. The committee gathered, tracked, and

shared patient handling injury data. The process to review the quality of entries in the EHR met selected requirements: A committee reviewed EHR quality. A committee analyzed data at least

quarterly. Reviews included data from most services

and program areas. The policy for scanning internal forms into EHRs included the following required items: Quality of the source document and an

alternative means of capturing data when the quality of the document is inadequate. A correction process if scanned items

have errors. A complete review of scanned documents

to ensure readability and retrievability of the record and quality assurance reviews on a sample of the scanned documents.

Overall, if QM reviews identified significant issues, the facility took actions and evaluated them for effectiveness.



NM Areas Reviewed (continued) Findings Recommendations Overall, senior managers actively participated in performance improvement over the past 12 months. Overall, the facility had a comprehensive, effective QM program over the past 12 months. The facility met any additional elements required by VHA or local policy.



EOC

The purpose of this review was to determine whether the facility maintained a clean and safe health care environment in accordance with applicable requirements. We also determined whether the facility met selected requirements in the CLC.b

We inspected the audiology, dental, optometry, Patient Aligned Care Team 1, and women veterans’ health clinics; the CLC areas (adult day health care, hospice and palliative care, ventilator unit, and dementia and rehabilitation unit); inpatient MH; and same day surgery. We also performed perimeter inspections of the Building 49 floors 1 and 2 and the Building 29 infusion clinic construction sites. Additionally, we reviewed relevant documents and 53 CLC employee training records and conversed with key employees and managers. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed for General EOC Findings Recommendations EOC Committee minutes reflected sufficient detail regarding identified deficiencies, corrective actions taken, and tracking of corrective actions to closure for the facility and the community based outpatient clinics. The facility conducted an infection prevention risk assessment. Infection Prevention/Control Committee minutes documented discussion of identified high-risk areas, actions implemented to address those areas, and follow-up on implemented actions and included analysis of surveillance activities and data. The facility had established a process for cleaning equipment. Selected employees received training on updated requirements regarding chemical labeling and safety data sheets. The facility met fire safety requirements. The facility met environmental safety requirements.



NM Areas Reviewed for General EOC (continued)

Findings Recommendations

The facility met infection prevention requirements. The facility met medication safety and security requirements. The facility met auditory privacy requirements. The facility complied with any additional elements required by VHA, local policy, or other regulatory standards.

Areas Reviewed for Critical Care NA Designated critical care employees received

bloodborne pathogens training during the past 12 months.

NA Alarm-equipped medical devices used in critical care were inspected/checked according to local policy and/or manufacturers’ recommendations.

NA The facility met fire safety requirements in critical care.

NA The facility met environmental safety requirements in critical care.

NA The facility met infection prevention requirements in critical care.

NA The facility met medication safety and security requirements in critical care.

NA The facility met medical equipment requirements in critical care.

NA The facility met patient privacy requirements in critical care.

NA The facility complied with any additional elements required by VHA, local policy, or other regulatory standards.



NM Areas Reviewed for CLC Findings Recommendations Designated CLC employees received bloodborne pathogens training during the past 12 months.

NA For CLCs with resident animal programs, the facility conducted infection prevention risk assessments and had policies addressing selected requirements. For CLCs with elopement prevention systems, the facility documented functionality checks at least every 24 hours and documented complete system checks annually. The facility met fire safety requirements in the CLC. The facility met environmental safety requirements in the CLC. The facility met infection prevention requirements in the CLC. The facility met medication safety and security requirements in the CLC. The facility met medical equipment requirements in the CLC. The facility met privacy requirements in the CLC. The facility complied with any additional elements required by VHA, local policy, or other regulatory standards. Areas Reviewed for Construction Safety

The facility met selected dust control, temporary barrier, storage, and security requirements for the construction site perimeter. The facility complied with any additional elements required by VHA or local policy, or other regulatory standards.




The purpose of this review was to determine whether the facility had established safe medication storage practices in accordance with VHA policy and Joint Commission standards.c

We reviewed relevant documents, the training records of 20 nursing employees, and pharmacy monthly medication storage area inspection documentation for the past 6 months. Additionally, we inspected the inpatient MH, CLC, urgent care, and post-anesthesia care unit patient care areas and for these areas reviewed documentation of narcotic wastage from automated dispensing machines and inspected crash carts containing emergency medications. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed Findings Recommendations Facility policy addressed medication receipt in patient care areas, storage procedures until administration, and staff authorized to have access to medications and areas used to store them. The facility required two signatures on controlled substances partial dose wasting. The facility defined those medications and supplies needed for emergencies and procedures for crash cart checks, checks included all required elements, and the facility conducted checks with the frequency required by local policy. The facility prohibited storage of potassium chloride vials in patient care areas. If the facility stocked heparin in concentrations of more than 5,000 units per milliliter in patient care areas, the Chief of Pharmacy approved it.



NM Areas Reviewed (continued) Findings Recommendations The facility identified in writing its high-alert and hazardous medications, ensured the high-alert list was available for staff reference, and had processes to manage these medications. The facility conducted and documented inspections of all medication storage areas at least every 30 days, fully implemented corrective actions, and monitored the changes. The facility/Pharmacy Service had a written policy for safe use of automated dispensing machines that included oversight of overrides and employee training and minimum competency requirements for users, and employees received training or competency assessment in accordance with local policy. The facility employed practices to prevent wrong-route drug errors. Medications prepared but not immediately administered contained labels with all required elements. The facility removed medications awaiting destruction or stored them separately from medications available for administration. The facility met multi-dose insulin pen requirements. The facility complied with any additional elements required by VHA or local policy.




The purpose of this review was to evaluate the consult management process and the completion of inpatient clinical consults.4

We reviewed relevant documents, and we conversed with key employees. Additionally, we reviewed the EHRs of 47 randomly selected patients who had a consult requested during an acute care admission from January 1 through June 30, 2014. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed Findings Recommendations A committee oversaw the facility’s consult management processes. Major bed services had designated employees to: Provide training in the use of the

computerized consult package Review and manage consults Consult requests met selected requirements: Requestors included the reason for the

consult. Requestors selected the proper consult

title. Consultants appropriately changed consult

statuses, linked responses to the requests, and completed consults within the specified timeframe.

The facility met any additional elements required by VHA or local policy.



Continuity of Care

The purpose of this review was to evaluate whether clinical information from patients’ community hospitalizations at VA expense was scanned and available to facility providers and whether providers documented acknowledgement of it.5

We reviewed relevant documents and the EHRs of 30 patients who had been hospitalized at VA expense in the local community from May 1, 2013, through April 30, 2014. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed Findings Recommendations Clinical information was consistently available to the primary care team for the clinic visit subsequent to the non-VA hospitalization. Members of the patients’ primary care teams documented that they were aware of the patients’ non-VA hospitalization. The facility complied with any additional elements required by VHA or local policy.



MRI Safety

The purpose of this review was to determine whether the facility ensured safety in MRI in accordance with VHA policy requirements related to: (1) staff safety training, (2) patient screening, and (3) risk assessment of the MRI environment.6

We reviewed relevant documents and the training records of 20 employees (11 Level 1 ancillary staff and 9 designated Level 2 MRI personnel), and we conversed with key managers and employees. We also reviewed the EHRs of 35 randomly selected patients who had an MRI January 1 through December 31, 2013. Additionally, we conducted a physical inspection of the MRI area. The table below shows the areas reviewed for this topic. The area marked as NM did not meet applicable requirements and needed improvement. Any items that did not apply to this facility are marked NA.

NM Areas Reviewed Findings Recommendations The facility completed an MRI risk assessment, had documented procedures for handling emergencies in MRI, and conducted emergency drills in the MRI area. Patients had two safety screenings conducted prior to MRI; the patient, family member, or caregiver signed the secondary patient safety screening form; and a Level 2 MRI personnel reviewed and signed the secondary patient safety screening form.

X Secondary patient safety screening forms contained notations of any MRI contraindications, and a Level 2 MRI personnel and/or radiologist addressed the contraindications and documented resolution prior to MRI.

Fifteen of the 31 applicable EHRs (48 percent) did not contain documentation that a Level 2 MRI personnel and/or radiologist addressed all identified contraindications prior to MRI.

1. We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.

The facility designated Level 1 ancillary staff and Level 2 MRI personnel and ensured they received level-specific annual MRI safety training.



NM Areas Reviewed (continued) Findings Recommendations The facility had signage and barriers in place to prevent unauthorized or accidental access to Zones III and IV. MRI technologists maintained visual contact with patients in the magnet room and two-way communication with patients inside the magnet, and the facility regularly tested the two-way communication device. The facility provided patients with MRI-safe hearing protection for use during the scan. The facility had only MRI-safe or compatible equipment in Zones III and IV or appropriately protected the equipment from the magnet. The facility complied with any additional elements required by VHA or local policy.



EAM

The purpose of this review was to determine whether the facility complied with selected VHA out of operating room airway management requirements.7

We reviewed relevant documents, including competency assessment documentation of three clinicians applicable for the review period January 1 through June 30, 2014, and we conversed with key managers and employees. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed Findings Recommendations The facility had a local EAM policy or had a documented exemption.

NA If the facility had an exemption, it did not have employees privileged to perform procedures using moderate or deep sedation that might lead to airway compromise. Facility policy designated a clinical subject matter expert, such as the Chief of Staff or Chief of Anesthesia, to oversee EAM. Facility policy addressed key VHA requirements, including: Competency assessment and

reassessment processes Use of equipment to confirm proper

placement of breathing tubes A plan for managing a difficult airway Initial competency assessment for EAM included: Subject matter content elements and

completion of a written test Successful demonstration of procedural

skills on airway simulators or mannequins Successful demonstration of procedural

skills on patients



NM Areas Reviewed (continued) Findings Recommendations NA Reassessments for continued EAM

competency were completed at the time of renewal of privileges or scope of practice and included: Review of clinician-specific EAM data Subject matter content elements and

completion of a written test Successful demonstration of procedural

skills on airway simulators or mannequins At least one occurrence of successful

airway management and intubation in the preceding 2 years, written certification of competency by the supervisor, or successful demonstration of skills to the subject matter expert

A statement related to EAM if the clinician was not a licensed independent practitioner

The facility had a clinician with EAM privileges or scope of practice or an anesthesiology staff member available during all hours the facility provided patient care. Video equipment to confirm proper placement of breathing tubes was available for immediate clinician use. The facility complied with any additional elements required by VHA or local policy.



MH RRTP

The purpose of this review was to determine whether the facility’s domiciliary RRTPs complied with selected EOC requirements.8

We reviewed relevant documents, inspected the domiciliary RRTPs, and conversed with key employees. The table below shows the areas reviewed for this topic. Any items that did not apply to this facility are marked NA. The facility generally met requirements. We made no recommendations.

NM Areas Reviewed Findings Recommendations The residential environment was clean and in good repair. Appropriate fire extinguishers were available near grease producing cooking devices. There were policies/procedures that addressed safe medication management and contraband detection. MH RRTP employees conducted and documented monthly MH RRTP self-inspections that included all required elements, submitted work orders for items needing repair, and ensured correction of any identified deficiencies. MH RRTP employees conducted and documented contraband inspections, rounds of all public spaces, daily bed checks, and resident room inspections for unsecured medications. The MH RRTP had written agreements in place acknowledging resident responsibility for medication security. MH RRTP main point(s) of entry had keyless entry and closed circuit television monitoring, and all other doors were locked to the outside and alarmed.



NM Areas Reviewed (continued) Findings Recommendations The MH RRTP had closed circuit television monitors with recording capability in public areas but not in treatment areas or private spaces and signage alerting veterans and visitors of recording. There was a process for responding to behavioral health and medical emergencies, and MH RRTP employees could articulate the process. In mixed gender MH RRTP units, women veterans’ rooms had keyless entry or door locks, and bathrooms had door locks. Residents secured medications in their rooms. The facility complied with any additional elements required by VHA or local policy.


CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix A

Facility Profile (St. Cloud/656) FY 2015 through November 20142

Type of Organization Secondary Complexity Level 3-Low complexity Affiliated/Non-Affiliated Affiliated Total Medical Care Budget in Millions $207 Number of: Unique Patients 19,836 Outpatient Visits 54,258 Unique Employees3 1,303

Type and Number of Operating Beds (as of October): Hospital 15 CLC 225 MH 148

Average Daily Census (as of October): Hospital 6 CLC 193 MH 112

Number of Community Based Outpatient Clinics 3 Location(s)/Station Number(s) Brainerd/656GA

Montevideo/656GB Alexandria/656GC

Veterans Integrated Service Network Number 23

2 All data is for FY 2015 through November 2014 except where noted. 3 Unique employees involved in direct medical care (cost center 8200) from most recent pay period.


CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix B

Strategic Analytics for Improvement and Learning (SAIL)4

4 Metric definitions follow the graphs.



Scatter Chart

FY2014Q3 Quintile



Metric Definitions

Measure Definition Desired direction

ACSC Hospitalization Ambulatory care sensitive condition hospitalizations (observed to expected ratio) A lower value is better than a higher value

Adjusted LOS Acute care risk adjusted length of stay A lower value is better than a higher value

Best Place to Work Overall satisfaction with job A higher value is better than a lower value

Call Center Responsiveness Average speed of call center responded to calls in seconds A lower value is better than a higher value

Call Responsiveness Call center speed in picking up calls and telephone abandonment rate A lower value is better than a higher value

Complications Acute care risk adjusted complication ratio A lower value is better than a higher value

Efficiency Overall efficiency measured as 1 divided by SFA (Stochastic Frontier Analysis) A higher value is better than a lower value

Employee Satisfaction Overall satisfaction with job A higher value is better than a lower value

HC Assoc Infections Health care associated infections A lower value is better than a higher value

HEDIS Outpatient performance measure (HEDIS) A higher value is better than a lower value

MH Status MH status (outpatient only, the Veterans RAND 12 Item Health Survey) A higher value is better than a lower value

MH Wait Time MH wait time for new and established patients (top 50 clinics; FY13 and later) A higher value is better than a lower value

Oryx Inpatient performance measure (ORYX) A higher value is better than a lower value

Physical Health Status Physical health status (outpatient only, the Veterans RAND 12 item Health Survey) A higher value is better than a lower value

Primary Care Wait Time Primary care wait time for new and established patients (top 50 clinics; FY13 and later) A higher value is better than a lower value

PSI Patient safety indicator (observed to expected ratio) A lower value is better than a higher value

Pt Satisfaction Overall rating of hospital stay (inpatient only) A higher value is better than a lower value

RN Turnover Registered nurse turnover rate A lower value is better than a higher value

RSMR-AMI 30-day risk standardized mortality rate for acute myocardial infarction A lower value is better than a higher value

RSMR-CHF 30-day risk standardized mortality rate for congestive heart failure A lower value is better than a higher value

RSMR-Pneumonia 30-day risk standardized mortality rate for pneumonia A lower value is better than a higher value

RSRR-AMI 30-day risk standardized readmission rate for acute myocardial infarction A lower value is better than a higher value

RSRR-CHF 30-day risk standardized readmission rate for congestive heart failure A lower value is better than a higher value

RSRR-Pneumonia 30-day risk standardized readmission rate for pneumonia A lower value is better than a higher value

SMR Acute care in-hospital standardized mortality ratio A lower value is better than a higher value

SMR30 Acute care 30-day standardized mortality ratio A lower value is better than a higher value

Specialty Care Wait Time Specialty care wait time for new and established patients (top 50 clinics; FY13 and later) A higher value is better than a lower value


CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix C

Veterans Integrated Service Network Director Comments

Department of MemorandumVeterans Affairs

Date: December 17, 2014

From: Director, VA Midwest Health Care Network (10N23)

Subject: CAP Review of the St Cloud VA Health Care System, St. Cloud, MN

To: Director, Denver Office of Healthcare Inspections (54DV)

Director, Management Review Service (VHA 10AR MRS OIG CAP CBOC)

I have reviewed and concur with the findings and recommendations in the draft report of the Office of Inspector General Combined Assessment Program Review conducted the week of November 2, 2014. Specific corrective actions have been provided for the recommendation.

JANET P. MURPHY, MBA


CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix D

Facility Director Comments

Department of MemorandumVeterans Affairs

Date: December 17, 2014

From: Director, St. Cloud VA Health Care System (656/00)

Subject: CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN

To: Director, VA Midwest Health Care Network (10N23)

1. I have reviewed and concur with the findings and recommendations in the draft report of the Office of Inspector General Combined Assessment Program Review conducted the week of November 2, 2014. Specific corrective actions have been provided for the recommendation.

2. Should you have any questions, please contact Carrie Fassler, Director, Quality, Safety and Value at 320-252-1670, x6723.

BARRY I. BAHL Health Care System Director



Comments to OIG’s Report

The following Director’s comments are submitted in response to the recommendations in the OIG report:

OIG Recommendation

Recommendation 1. We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance

Concur

Target date for completion: Staff Education completed November 7, 2014. Update to MRI electronic Safety Sheet to be completed January 31, 2015. By September 30, 2015 the process will be complete through auditing of charts.

Facility response: The process for ensuring that Radiologists and Level 2 MRI personnel document resolution in patients’ electronic health records identifying MRI contraindications prior to the scan was reviewed. Staff was immediately educated to document resolution of contraindications prior to the MRI scan.

An update to the MRI Safety Sheet in the patient’s electronic health record is currently being developed. The update will require a response through a radio button to any MRI contraindication assuring documentation of resolution to a contraindication.

Joint Commission sampling standards were utilized to implement a documentation audit that began on December 1, 2014 and will be completed on September 30, 2015. Audit results will be reported on the Imaging Department’s Process Improvement Plan and to the MRI Safety Committee.


CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix E

Office of Inspector General Contact and Staff Acknowledgments

Contact For more information about this report, please contact the OIG at (202) 461-4720.

Inspection Team Cheryl Walker, ARNP, MBA, Team Leader Michael Bishop, MSW Laura Dulcie, BSEE Ann Ver Linden, RN, MBA, Clarissa Reynolds, CNHA, MBA Randy Rupp, Special Agent, Office of Investigations

Other Elizabeth Bullock Contributors Shirley Carlile, BA

Paula Chapman, CTRS Lin Clegg, PhD Marnette Dhooghe, MS Patrick Smith, M. Stat Julie Watrous, RN, MS Jarvis Yu, MS


CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix F

Report Distribution

VA Distribution

Office of the Secretary Veterans Health Administration Assistant Secretaries General Counsel Director, VA Midwest Health Care Network (10N23) Director, St. Cloud VA Health Care System (656/00)

Non-VA Distribution

House Committee on Veterans’ Affairs House Appropriations Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies House Committee on Oversight and Government Reform Senate Committee on Veterans’ Affairs Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies Senate Committee on Homeland Security and Governmental Affairs National Veterans Service Organizations Government Accountability Office Office of Management and Budget U.S. Senate: Al Franken, Amy Klobuchar U.S. House of Representatives: Tom Emmer, Rick Nolan, Collin C. Peterson

This report is available at www.va.gov/oig.


http://www.va.gov/oig

CAP Review of the St. Cloud VA Health Care System, St. Cloud, MN Appendix G

Endnotes

a References used for this topic included: VHA Directive 1026, VHA Enterprise Framework for Quality, Safety, and Value, August 2, 2013. VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011. VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. VHA Directive 2010-032, Safe Patient Handling Program and Facility Design, June 28, 2010. VHA Directive 1036, Standards for Observation in VA Medical Facilities, February 6, 2014. VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012. VHA Handbook 1102.01, National Surgery Office, January 30, 2013. VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility

Cardiopulmonary Resuscitation Committees, October 17, 2008. VHA Handbook 1907.01, Health Information Management and Health Records, July 22, 2014. b References used for this topic included: VHA Directive 2010-052, Management of Wandering and Missing Patients, December 3, 2010. VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011. Under Secretary for Health, “Non-Research Animals in Health Care Facilities,” Information Letter 10-2009-007,

June 11, 2009. Various requirements of The Joint Commission, the Occupational Safety and Health Administration, the

International Association of Healthcare Central Service Materiel Management, the National Fire Protection Association, the Health Insurance Portability and Accountability Act, Underwriters Laboratories.

c References used for this topic included: VHA Directive 2008-027, The Availability of Potassium Chloride for Injection Concentrate USP, May 13, 2008. VHA Directive 2010-020, Anticoagulation Therapy Management, May 14, 2010. VHA Handbook 1108.01, Controlled Substances (Pharmacy Stock), November 16, 2010. VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006. VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006. VHA Handbook 1108.07, Pharmacy General Requirements, April 17, 2008. Various requirements of The Joint Commission. 4 The reference used for this topic was: Under Secretary for Health, “Consult Business Rule Implementation,” memorandum, May 23, 2013. 5 The references used for this topic were: VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. Various requirements of the Joint Commission. 6 References used for this topic included: VHA Handbook 1105.05, Magnetic Resonance Imaging Safety, July 19, 2012. Emanuel Kanal, MD, et al., “ACR Guidance Document on MR Safe Practices: 2013,” Journal of Magnetic

Resonance Imaging, Vol. 37, No. 3, January 23, 2013, pp. 501–530. The Joint Commission, “Preventing accidents and injuries in the MRI suite,” Sentinel Event Alert, Issue 38,

February 14, 2008. VA National Center for Patient Safety, “MR Hazard Summary,”

http://www.patientsafety.va.gov/professionals/hazards/mr.asp. VA Radiology, “Online Guide,” http://vaww1.va.gov/RADIOLOGY/OnLine_Guide.asp, updated

October 4, 2011. 7 References used for this topic included: VHA Directive 2012-032, Out of Operating Room Airway Management, October 26, 2012. VHA Handbook 1101.04, Medical Officer of the Day, August 30, 2010. 8 References used for this topic were: VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program (MH RRTP),

December 22, 2010. VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010. Requirements of the VHA Center for Engineering and Occupational Safety and Health and the National Fire

Protection Association.


http://www.patientsafety.va.gov/professionals/hazards/mr.asp

http://vaww1.va.gov/RADIOLOGY/OnLine_Guide.asp

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